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Bereavement Does Not Immunize the Grieving Person Against Major Depression

This is a guest post by Dr. Ronald Pies in response to this week's GeriPal post about the removal of the Bereavement Exclusion from DSM-5. Dr. Pies is the Editor-in-Chief Emeritus of Psychiatric Times, Professor of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical University, and Clinical Professor of Psychiatry at Tufts USM.

Dr. Widera is quite right: ordinary grief is not an illness, has adaptive value, and does not require professional treatment. But grieving persons are not immune to major depressive disorder (MDD), and, indeed, bereavement is a common trigger for MDD. There are, nevertheless, substantial differences between grief and MDD, and experienced clinicians will be able to tell the difference. The elimination of the bereavement exclusion from DSM-5 will not change that. Let’s consider the following scenario:

Mr. Smith is a 72-year-old retired businessman whose wife died of cancer 3 weeks ago. He visits his family doctor and says, “I feel down in the dumps and weepy every day, Doc—really lousy! I don’t get any pleasure out of anything anymore, even stuff I used to love, like watching football on TV. I wake up at 4 in the morning almost every day, and I have zero energy. I can’t keep my mind on anything. I barely eat, and I’ve lost 10 pounds since Mary passed away. I hate being around other people. Sometimes I feel like I didn’t really do enough for Mary when she was sick. God, how I miss her! I can still cook for myself, pay the bills, and so on, Doc, but I’m just going through the motions. I don’t enjoy life at all anymore.”

Though it’s still early after his wife’s death—and some clinicians may want to defer a final diagnosis for another week—all clinicians should be very concerned about Mr. Smith. He easily meets DSM-IV (and now, DSM-5) symptom and duration criteria for MDD. (A previous bout of MDD in his history would strengthen the likelihood, as would several other clinical findings I have omitted). And yet, under the present DSM-IV “rules,” Mr. Smith probably would not be diagnosed with a major depressive illness. He would simply be called “bereaved.” Why? Because he is still within the 2-month period that allows for use of the bereavement exclusion; and because Mr. Smith doesn’t have the DSM-IV features that allow the clinician to “override” use of the BE; namely, severe functional impairment, suicidal ideation, psychosis, morbid preoccupation with worthlessness, or extreme guilt. It’s important to note that the DSM-IV exclusion rules did not apply to any other type of loss, such as losing one’s job or becoming homeless. Ironically, if Mr. Smith’s wife had left him for another man, he would meet MDD criteria, using current DSM-IV rules!

Many of us who have specialized in the treatment of mood disorders found the DSM-IV criteria not only illogical, but also inimical to good clinical care. We were concerned that many bereaved patients like Mr. Smith--who meet all symptom and duration criteria for MDD, but who happen to have lost a loved one within the past two months-- would be shunted out of the mental health care system. In the view of many (though not all) mood disorder specialists, the risk of overlooking MDD, with its high potential for suicide, far outweighs the less serious risk of “over-calling” MDD—the so-called “false positive” scenario.

The elimination of the bereavement exclusion (BE) by the DSM-5 does not mean that “grief is now a mental disorder,” as some have claimed. Nor does it mean that anyone who is grieving within two weeks of a loved one’s death—i.e., most people!—will be diagnosed with major depressive disorder. (Two weeks is the minimum duration required for MDD, under DSM-IV and DSM-5 criteria). First of all, studies have shown that most bereaved persons will not meet full DSM-5 criteria for MDD. Second: it would be extremely rare, in clinical practice, for a bereaved person to seek psychiatric care within two weeks (or even a month) of the death of a loved one, unless something very unusual or dysfunctional were going on—for example, the bereaved person has developed a psychotic-level disturbance; is severely incapacitated; or has become suicidal--in which cases, the bereavement exclusion would not apply anyway. And, contrary to the strident claims of some, nothing in the diagnosis of MDD will prevent bereaved patients with MDD from receiving the love, support, and solace of family and friends.

To be sure, physicians and other health care workers need a much better understanding of the key differences between ordinary grief and major depression. For example, bereaved persons with normal grief often experience a mixture of sadness and more pleasant emotions, as they recall memories of the deceased. Anguish and pain are usually experienced in “waves” or “pangs,” rather than continuously, as is usually true in major depression. The grieving individual typically maintains the hope that things will get better. In contrast, the clinically depressed patient’s mood is almost uniformly one of gloom, despair, and hopelessness–nearly all day, nearly every day. The bereaved individual usually maintains a strong emotional connection with friends and family, and often can be consoled by them. The person suffering a severe major depressive disorder is usually too self-focused and emotionally “cut off” to enjoy the company of others. Indeed, Dr. Kay R. Jamison has pointed out that “The capacity to be consoled is a consequential distinction between grief and depression.” My colleagues and I are now developing a screening questionnaire (the PBPI) based on these distinctions. We don’t yet know the final wording of the DSM-5 text, which we hope will emphasize and clarify the distinctions between ordinary grief and major depression.

"I write this as one in the midst of bereavement, having lost my dear mother several months ago... During the last year of her life (in rehab facilities and briefly in a nursing home) we were never closer. I still avoid driving by the nursing home. I still wake up at night occasionally tearfully thinking of her. I cook a lot of pot roasts in the old cast iron Dutch oven she made famous. I am converting a home office to a guest bedroom filled with family memories. I am not ill. I am grieving. It doesn’t look like illness. It doesn’t need to be treated like illness. I can’t believe anyone would mistake it for illness, especially an experienced clinician. But if I were ill and grieving, I would expect my health care providers to understand that the two concepts are not mutually exclusive, and I would expect them to offer help for my illness . . .Part of my practice is in a mood disorders clinic in a family practice residency...I cannot remember a single instance in this setting where the [bereavement exclusion] saved the day, preventing the unnecessary use of medication for a non-illness. In situations in which previous ill episodes were absent, symptoms were mild, and cognition and function were preserved, we would always choose the path of supportive and cognitive psychotherapy, and bibliotherapy or other non-pharmacological means as primary interventions. However, in patients with severe symptoms or those with documented histories of Axis I illness, we would never ignore the reality that intact affective control systems are a requirement for successful negotiation of grief."

In conclusion: eliminating the bereavement exclusion means essentially this: the death of a loved one--a common precipitant of major depression----will no longer be a "disqualifying" factor in diagnosing MDD, within the first few weeks after bereavement. This emphatically does not mean that we should be starting everyone with bereavement-related MDD on antidepressants! Some depressed and bereaved patients will heal and recover with "tincture of time"; some will benefit from cognitive, supportive or grief-oriented psychotherapies. More severely depressed, grieving patients--those, for example, with melancholic features or pronounced suicidality--may require concurrent medication and psychotherapy.

No, indeed: we must not "medicalize" normal grief. But neither must we "normalize" major depression, simply because it occurs in the context of bereavement.

Jamison KR: Nothing Was the Same. Knopf, 2009. Also: an excellent video with Dr. Kay R. Jamison explains some of the key differences between grief and depression: http://bigthink.com/ideas/16707

Acknowledgments:Thanks to Laura Dunn, MD and Sidney Zisook MD, for suggestions on earlier drafts of this blog; however, the views expressed here are my own.

Disclosure statement: Dr. Pies reports no financial or other conflicts of interest with respect to the content of this piece. He has had no official role in the DSM-5 development process, or any formal connection to the DSM-5 committees. He receives no monies from any pharmaceutical companies. A formal disclosure statement may be found at: http://www.psychiatrictimes.com/editorial-board

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Ronald Pies MD said…

My sincere thanks to Dr. Widera and GeriPal for "hosting" this piece. I hope readers will benefit from the range of ideas discussed in both Dr. Widera's piece, and mine.

Very helpful article and the list of further resources is much appreciated. You raise important points about how mental health professionals are exactly that: well trained professionals who use the DSM, whatever version, with as much wisdom and clinical excellence as possible. I do continue to worry about public perception of the change. As a hospice professional, I have been chagrined over the years to encounter countless grieving individuals who never read Kubler-Ross directly but had a very stringent view that there were 5 distinct stages to grief, and by golly they were going to travel through them, in order, and be done with it! Or families of patients who would talk about "pulling the plug" on the loved on as a way of understanding the choice to move from mainly curative to mainly palliative in care. Any suggestions for how to combat the pop psychology interpretations of this change?

Many thanks for your note, Ms. Ziettlow (sorry if I have your title wrong...).

I think you are right that the concepts of "grief" and "grieving" are greatly misunderstood, not only among the general public, but among even many health care professionals. I often find highly polarized views in the general public. There is the "Pull yourself together and suck it up!" view (the "stiff upper lip" approach to grief and loss; and then the other extreme of "You need to pass through all five stages of grief, or there is something really wrong with you!" (the "enforcer" approach, based on a superficial reading of Kubler-Ross).

An excellent paper by George Bonanno et al (Journal of Personality and Social Psychology 2002, Vol. 83, No. 5, 1150–1164) makes clear that people grieve in all sorts of ways, and that we need to avoid criticizing or condemning any particular pattern. Bonanno et al write:

"...the wide range of grief patterns demonstrated in thepresent study suggests a need to reevaluate common notions aboutwhat constitutes a normal response to a major loss. Of course, views about normal grieving are not only prevalent among researchers and health care providers...but also among lay people and the bereaved themselves. Because they are unaware of the striking variability in response to loss,potential supporters are often critical or judgmental of bereavedindividuals who show too much or too little grief."

As for educating the public about the change from DSM-IV to DSM-5, this will be an uphill struggle, since there is so much suspicion surrounding psychiatry these days; e.g., "the DSM is just the work of Big Pharma!", etc. (Even Dr. Allen Frances, a persistent critic of the DSM-5, has repudiated that view). As a good introduction to grief, complicated grief, and major depression (all of which are distinct entities), I recommend reading the paper by my colleagues, Sidney Zisook MD and Kathy Shear MD. You can find the complete version online:Grief and bereavement: what psychiatrists need to know, World Psychiatry 2009;8:67-74.

Thanks Dr. Pies for your thoughtful post! I wonder how you would respond to today's NPR story about the issue. In particular, how do you respond to this part of Jerome Wakefield's argument:

"So, to me, it doesn't really make sense to - on the basis of worrying that you're going to miss a case that's more severe - to eliminate the bereavement exclusion, because the bereavement exclusion already takes account of the fact that anybody who's severe should be diagnosed anyway."

Here is the link to the full story: http://www.npr.org/2012/12/06/166682774/psychiatrists-to-take-new-approach-in-bereavement

I was pleased to see NPR covering this important issue, but was disappointed that only one side of the debate was given prominent coverage. The main reasons the so-called bereavement exclusion was eliminated from the DSM-5 are: (1) there was never any well-controlled, clinical evidence showing that major depressive symptoms following the death of a loved one differ in any important ways from depression in any other context; and (2) major depression is a potentially lethal disorder, with a suicide rate sometimes approaching 1 in 10. Disqualifying a patient from a diagnosis of major depression simply because he or she experiences it after the death of a loved one risks closing the door on adequate and potentially life-saving treatment. Contrary to claims by some, "treatment" need not involve antidepressant medication, except in the most severe cases. Psychotherapy is also appropriate in cases of bereavement-related major depressive symptoms, though it is true that this option is not easily available in our present dysfunctional health care system.

To be sure: ordinary grief is not a disorder, and does not require professional treatment. There are indeed recognizable differences between ordinary grief and major depression. For example, bereaved persons with normal grief often experience a mixture of sadness and more pleasant emotions, as they recall memories of the deceased. Anguish and pain are usually experienced in “waves” or “pangs,” rather than continuously, as is usually true in major depression. The grieving individual typically maintains the hope that things will get better. In contrast, the clinically depressed patient’s mood is almost uniformly one of gloom, despair, and hopelessness–nearly all day, nearly every day.

But the ordinarily-grieving person is unlikely to seek professional help, within the first month or two after the death of a loved one. Often, it is the bereaved patient himself or herself--or a family member--who senses the need for professional help, because he or she knows something has gone seriously wrong. Indeed, normal grief is itself hampered when symptoms of major depression have intervened and clouded the picture.

While the "old" DSM-IV criteria provided a mechanism to override the bereavement exclusion--for example, if the depressed, bereaved patient is psychotic, suicidal, or unable to function in daily life--there are many patients whose depressive symptoms are severe but who do not "qualify" for the old, override criteria. Under the DSM-IV "rules", these patients would not have received a diagnosis of major depressive disorder, and likely would not have received appropriate treatment. The DSM-5 no longer shuts these patients out of the mental health treatment setting, which would risk deterioration in their condition and even the possibility of death.

No, we should not "medicalize" ordinary grief. But neither should we "normalize" major depression, simply because it occurs in the context of a recent death.

Medical providers shouldn't overlook the bereavement period related to a death. Considering the stress the grieving relatives had to endure throughout the period, they are a lot more susceptible to breakdowns at this time, so their mental and physical health has to be maintained.

In a way, the shift was a good thing. At least, it cleared up some of the grey areas created by the rules set up by DSM-IV, and it allows doctors to intervene as early as possible once they spot something wrong. However, this might lead to some misconceptions if the physician still does not understand the varying grieving patterns his patients have.

My thanks to Drs. Wilkes and Louis for their helpful comments, with which I agree.

The new DSM-5--for all the criticism it deserves or does not deserve--"got it right" on the matter of the bereavement exclusion, and provides some decent guidelines for distinguishing grief from major depression. I will be posting a blog on Psychcentral very shortly that I hope will further clarify this issue.

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